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THE GASTROINTESTINAL SYSTEM

EXAMINATION
HISTORY
You need to know common causes of, and be able to fully
explore common symptoms of the following gastrointestinal :
•Dysphagia
•Heartburn and acid reflux
•Dyspepsia
•Nausea, vomiting, haematemesis
•Abdominal Pain
•Altered bowel habit
•Rectal bleeding and melaena
•Abdominal distension
•Anorexia and weight loss
Urinary and Prostate symptoms
Think about how you can use the mnemonic
SQITARPS to help you explore these symptoms.
For example there are many questions that could be asked
about vomiting
•Site: The quality of the vomit often gives an indication of
the site of the problem.
•Quality: What are they vomiting? E.g. food, bile, blood.
If blood is it fresh and red or partially digested (like coffee
grounds).
•Intensity: How frequent or forceful is the vomiting? What
volume? Are there signs of hypovolaemia in
haematemesis? Are they actively vomiting or does blood
well up in the mouth?
•Timing: How long has it been present and how has it
changed over this time? E.g. food initially and then
blood. Does it change during the course of a day?
•Aggravating factors: Are they on any medication?
Eating? Alcohol?
•Relieving factors: Have they taken any medication?
•Previous episodes: Is there a pattern?
•Secondary (or associated) symptoms: Ask about other
GI symptoms, consider neurological symptoms, trauma,
weight loss
PHYSICAL EXAMINATION
Overview
The abdominal examination should include the following:
•General inspection from the end of the bed.
•General examination of:
•Hands / pulse
•Face and neck ( including lymph nodes)
•Feet and legs
Examination of the abdomen.
•Inspection
•Palpation
•Percussion
•Auscultation
Preparation
Introduce yourself to the patient if you have not already
done so and
check the identity of the patient
•Wash your hands
•Ask the patients permission to carry out the examination
•Give a brief explanation to the patient before you start.
Further
•explanation/instructions can be given as you proceed.
Equipment
•Stethoscope
•Pair of gloves
•Tongue depressor
•Thermometer
•Patient position: Ideally the patient should be lying flat
with the head
propped on a single pillow and the arms at the sides.
•Exposure: When you are ready to examine the abdomen
it should be
exposed from above the costal margins to the level of the
symphysis pubis(mid-thighs is better to inspect the groins
well).
General Observations
Check visually from the end of the bed. Note:
•Obvious discomfort/pain, breathlessness, distension
•Colour
•Items around the bed (e.g. catheter bag, cannulas, NG
tubes,
drains, IV fluids)
HANDS
Inspect both hands; nails, back and then palms.
You should be able to recognise, and know the significance of, :
•Anaemia
•Dehydration
•Clubbing
•Leukonychia
•Koilonychias
•Palmar erythema
•Dupuytren's contracture
•Spider-naevi
•Muscle wasting (Thenar, hypothenar, and interossei)
Feel the radial pulse. Note the
•Rate
•Rhythm
•Volume
Check for hepatic flap of liver failure (if appropriate)
•Ask patient to stretch arms out in front of them with the wrists
dorsiflexed and fingers extended.
•Look for irregular, jerky flexion/extension at the wrists and MCP joints

EYES
Gently pull down lower eyelids and ask the patient to look up. Inspect
for:
•pale conjunctiva of anaemia
•yellow sclera of jaundice - ideally in natural light (upper eyelid)
MOUTH
Ask patient to open their mouth. Inspect the teeth, tongue, gums and
inner surface of the cheeks
You should be able to recognise, and know the significance of the
following:
•Ulcers
•Candidiasis
•Changes to the tongue e.g. glossitis, macroglossia.

Note any obvious odour of the patients breath e.g.


•Fetor hepaticus
•Ketosis
•Uraemia
Acute appendicitis
THE ABDOMEN
INSPECTION
With the abdomen exposed, you should be able to recognise, and know the significance
of, the following:
•Abdominal distension and asymmetry
•Umbilicus (normally inverted)
•Focal swelling
•Mode of respiration (Abdomino-thoracic or thoraco-abdominal)
•Movement of abdomen with respiration (absent in peritonism)
•Dilated/prominent veins
•Visible peristalsis
•Obvious pulsation
•Skin discolouration or pigmentation or tattooing.
•Hair distribution
•Scars
•Surgical stomas (ileostomy, colostomy, conduit,…etc)
•Cough impulse and look at both groins, periumbilical area, epigastric area, scars and
stomas to detect corresponding hernias
PALPATION
You should be at the same level as the patient to palpate the abdomen,
looking at the patients face for any signs of discomfort. Remember to
examine any areas of tenderness last. Ask the patient if they have any
pain before commencing.
The abdomen should be examined by light (superficial) and deep
palpation in all 9 areas before examining specific organs checking for
masses or tenderness. The order they are examined in does not matter.

Light Palpation
•Gently palpate all nine areas
•Start away from known pain.
•Hold your hand flat, and gently press in by extending at the MCP
joints to palpate with the palmar surface of your finger - not digging in
with your fingertips.
Rebound Tenderness
pain is worse when you release pressure on the abdomen than when you
press down - this is a sign of peritoneal irritation
If there is pain on light palpation, try and determine if this is rebound
tenderness
Deep Palpation
Re-examine using the same technique but now using more pressure. Note
any masses or structural abnormality.Masses should be described in
terms of
•Site •Overlying skin (erythema, ulceration, scar. …etc.)
•Size •Cough impulse
•Shape •Compressibility and reduccibility
•Surface •Movement with respiration.
•Consistency •Tenderness
•Mobility •Hotness
•Layer of origin (skin, subcutaneous tissue, •Percussion note
• abdominal wall, or intraabdominal) •Fluctuation
•Pulsatility and expansility
The Liver
The liver normally is either not palpable or just palpable 2 cm
below right costal margin. Span is 12-16 cm.
Start palpation from the right iliac fossa using the same
technique as before but angle your hand so that the index
finger is aligned with the costal margin .
Ask the patient to take breaths in and out as you proceed, and
feel for the descending liver edge on inspiration If the liver is
not felt move your hand 1-2cm superiorly toward the right
hypochondrium during expiration, ready to apply gentle
pressure again during inspiration
The Spleen
Start palpation from the right iliac fossa moving diagonally toward the
left hypochondrium . Ask the patient to take breaths in and out as you
proceed and use the same technique as for the liver
.
In healthy individuals the spleen is not palpable. It enlarges along the
line of the 9 rib and moves downwards and inwards on inspiration. The
spleen has a distinctive "notch‟ which can help to differentiate it from
other structures in splenomegaly. The spleen needs to enlarge 2-3 times
its normal size to be palpable.
Mild splenomegaly (SM): just palpable below left costal margin.
Moderate SM : reaches beyond half the way to umbilicus.
Massive SM: reaches beyond umbilicus.
The Kidneys
The kidneys are not normally palpable; however, you may feel
the lower pole of the right kidney in a thin person.

Place your left hand behind the patients back just below the
ribs at the right hand side Place your right hand on the
abdomen below the right costal margin just lateral to the rectus
abdominis. Ask the patient to breathe out and push your hands
together firmly (but gently). Ask the patient to breathe in.

You may feel the lower pole of the kidney moving down
between the hands If this happens try to "Ballot‟ or push the
kidney back and forward between your hands Repeat for the
left kidney by leaning over and placing the left hand under the
left loin.
How can differentiate enlarged spleen from left
kidney
1. The spleen has a notch.
2. The spleen is palpated with one hand, while the
kidney with two hands.
3. The spleen is dull to percussion while the kidney is
tympanic due to overlying colon.
4. The spleen moves more with respiration than the
kidney.
5. The spleen enlarges diagonally towards RIF, while
the left kidney moves towards LIF.
6. The spleen cannot be balloted , in contrast to the
kidney.
Bladder
Palpable suprapubically if full.Start palpation from umbilicus
with index finger horizontal and proceed inferiorly toward
symphysis pubis
Aorta
•Palpate in the vertical midline of abdomen above the
umbilicus.
•Place the fingers on either side of the outer margins, feeling
for pulsation
•Normal diameter is 2-3cm
•Palpable in most healthy people
PERCUSSION
You should percuss any lumps or masses identified on
palpation to determine their size and nature
Percuss individual organs to help determine their size (you
may see some clinicians percuss the 9 regions)
If the abdomen appears distended and you suspect the
presence of ascites test for "shifting dullness‟ and "fluid
thrill"
Percussion may reveal enlargement of the spleen that is not
detectable on palpation. This is because the spleen would
have to be 2-3 times its normal size to be palpable on
abdominal examination
PERCUSSION

The Liver
Percuss from right iliac fossa upwards
Identify both the lower and upper borders of the liver
Note the length in centimetres at the midclavicular line is
called span ‫ حجمه‬١٤‫فوك ال‬

The Spleen ‫يعتبر‬


‫ و‬enlargement
١٠ ‫اذا تحت ال‬
‫سمول سايز‬

Percuss from the right iliac fossa diagonally toward the left
hypochondrium. Continue percussing over the ribs toward the
midaxillary line and lower left ribs for dullness.
Bladder
Begin percussing from just above the umbilicus with the
finger positioned horizontally on the abdomen Percuss
inferiorly toward the symphysispubis.
Ascites and Shifting Dullness
Ascites is free fluid within the peritoneum. With the
patient lying on their back, gravity will cause the fluid
to move toward the patients back and the bowel will
float centrally.
When the patient is rolled to onto their side, the fluid
will be moved by gravity to the side they are lying on.
On percussion any dullness caused by the presence of
fluid will also move.
Shifting Dullness

•Percuss from the centre of the abdomen laterally with


the fingers positioned longitudinally until dullness is
detected.
•Keep your finger pressed there (or mark the spot with
a pen) as you ask the patient to roll on to the opposite
side to where you have marked
•Wait at least 30 seconds
•If the dullness was an air/fluid level, the previously
dull area will now be resonant as fluid is moved away
by gravity.
Repeat percussion moving from this point back toward
centre
Fluid Thrill
•Place your left hand flat against the left side of the
patients abdomen.
•Ask the patient to place the edge of one hand
longitudinally on midline of abdomen to prevent
transmission of the impulse via the skin.
•Tap on the right side of the abdomen with the right
hand.
•Feel for a ripple of fluid against the left hand.
AUSCULTATION
Bowel Sounds
Listen with the diaphragm of the stethoscope just below the umbilicus.
Describe findings you should be able to recognise and understand the
significance of:
•Normal
•Tinkling
•Absent bowel sounds.
You may have to listen for a while if the sounds are quiet (usually 1-2
minutes)
Bruits
Listen with the diaphragm of the stethoscope for turbulent blood flow
•Over the aorta, just above the umbilicus
•Over the renal arteries - just above and to either side of the umbilicus
•Over the liver (Cruveilhierbruit)

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